Short-term and long-term outcomes of single-incision versus multi-incision laparoscopic resection for colorectal cancer: a propensity-score-matched analysis of 214 cases

Two Cases of Single-Incision Laparoscopic Surgery for Sigmoid Colon and Rectal Cancer in Situs Inversus Totalis

INTRODUCTION

Situs inversus totalis (SIT) is a rare congenital disorder characterized by the complete inverted transposition of the thoracic and abdominal viscera. This anatomical variation complicates laparoscopic surgery, and there are currently no reports of single-incision laparoscopic surgery (SILS) for patients with sigmoid colon cancer or rectal cancer with SIT.

CASE PRESENTATION

We performed SILS on 2 patients with sigmoid colon and rectal cancers who also had SIT. The first case involved a 64-year-old woman with sigmoid colon cancer. A 3.5 cm umbilical incision was made, and SILS was performed using a single-port surgical device with three 5 mm trocars placed in the incision. The sigmoid colon was resected with a linear stapler, which required switching from a 5 mm trocar to a 12 mm trocar. Laparoscopic anastomosis was performed using the double-stapling technique. The second case involved an 81-year-old man with dual cancers located in the sigmoid colon and lower rectum, 8 cm from the anal verge. The abdominal approach was performed using SILS, similar to the first case, along with a transanal total mesorectal excision (TaTME) from the perineum by 2 teams. Anastomosis was performed laparoscopically using a single-stapling technique. Neither patient experienced postoperative complications, and both remained free of recurrence at 42 and 7 months, respectively.

CONCLUSIONS

SILS is a feasible approach for patients with sigmoid colon cancer or rectal cancer and SIT.

Long-term outcomes of single-incision laparoscopic colectomy for right-sided colon cancer utilising a craniocaudal approach

INTRODUCTION

This study aimed to evaluate the short- and long-term outcomes of single-incision laparoscopic colectomy (SILC) for right-sided colon cancer (CC) using a craniocaudal approach.

PATIENTS AND METHODS

The data of patients who underwent SILC for right-sided CC at our hospital between January 2013 and December 2022 were retrospectively collected. Surgery was performed using a craniocaudal approach. Short- and long-term operative outcomes were analysed.

RESULTS

In total, 269 patients (127 men, 142 women; median age 74 years) underwent SILC for right-sided CC. The cases included ileocaecal resection ( n = 138) and right hemicolectomy ( n = 131). The median operative time was 154 min, and the median operative blood loss was 0 ml. Twenty-seven cases (10.0%) required an additional laparoscopic trocar, and 9 (3.3%) were converted to open surgery. The Clavien-Dindo classification Grade III post-operative complications were detected in 7 (2.6%) cases. SILC was performed by 25 surgeons, including inexperienced surgeons, with a median age of 34 years. The 5-year cancer-specific survival (CSS) was 96.1% (95% confidence interval [CI] 91.3%-98.2%), and CSS per pathological disease stage was 100% for Stages 0-I and II and 86.2% (95% CI 71.3%-93.7%) for Stage III. The 5-year recurrence-free survival (RFS) was 90.6% (95% CI 85.7%-93.9%), and RFS per pathological disease stage was 100% for Stage 0-I, 91.7% (95% CI 80.5%-96.6%) for Stage II and 76.1% (95% CI 63.0%-85.1%) for Stage III.

CONCLUSIONS

SILC for right-sided CC can be safely performed with a craniocaudal approach, with reasonable short- and long-term outcomes.

Single-incision Laparoscopic Colonic Surgery: A Systemic Review, Meta-analysis, and Future Prospect

Although single-incision laparoscopic surgery (SILS) has gained some attention as a feasible alternative to conventional multiport laparoscopic surgery (MPLS) in colonic surgery, it became less prevalent than expected. Hence, we conducted this systematic review to evaluate the feasibility, safety, and oncological outcomes of single-incision laparoscopic colectomy (SILC) with meta-analysis and discussion of the future prospect of SILS. The search was conducted from September to October 2023 using PubMed and the Cochrane Central Register of Controlled Trials. Articles on colorectal cancer comparing SILC with multiport laparoscopic colectomy (MPLC) from all randomized controlled trials and comparative studies with 50 patients or more per arm were examined. The primary outcomes were the intra- and postoperative complication rates, and the secondary outcomes were the perioperative and oncological outcomes. The trends of the SILS number in Japan and the trends of the number of articles on SILS in PubMed were also reviewed. There were no significant differences in perioperative complication rates, operative factors, and oncological outcomes between SILC and MPLC, although heterogeneity was observed mainly in operative factors and the total length of the skin incision was significantly shorter in SILC. Therefore, SILC is technically and oncologically feasible and safe when performed by experienced laparoscopic surgeons. The case number of SILS was gradually increasing but the rate of SILS was decreasing in Japan. The number of articles on SILS was also decreasing. SILS has gained foothold to some extent but has plateaued. The emerging new robotic platform may reappraise the concept of SILS.

Artificial intelligence algorithms for predicting post-operative ileus after laparoscopic surgery

Objective

By constructing a predictive model using machine learning and deep learning technologies, we aim to understand the risk factors for postoperative intestinal obstruction in laparoscopic colorectal cancer patients, and establish an effective artificial intelligence-based predictive model to guide individualized prevention and treatment, thus improving patient outcomes.

Methods

We constructed a model of the artificial intelligence algorithm in Python. Subjects were randomly assigned to either a training set for variable identification and model construction, or a test set for testing model performance, at a ratio of 7:3. The model was trained with ten algorithms. We used the AUC values of the ROC curves, as well as accuracy, precision, recall rate and F1 scores.

Results

The results of feature engineering composited with the GBDT algorithm showed that opioid use, anesthesia duration, and body weight were the top three factors in the development of POI. We used ten machine learning and deep learning algorithms to validate the model, and the results were as follows: the three algorithms with best accuracy were XGB (0.807), Decision Tree (0.807) and Neural DecisionTree (0.807); the two algorithms with best precision were XGB (0.500) and Decision Tree (0.500); the two algorithms with best recall rate were adab (0.243) and Decision Tree (0.135); the two algorithms with highest F1 score were adab (0.290) and Decision Tree (0.213); and the three algorithms with best AUC were Gradient Boosting (0.678), XGB (0.638) and LinearSVC (0.633).

Conclusion

This study shows that XGB and Decision Tree are the two best algorithms for predicting the risk of developing ileus after laparoscopic colon cancer surgery. It provides new insight and approaches to the field of postoperative intestinal obstruction in colorectal cancer through the application of machine learning techniques, thereby improving our understanding of the disease and offering strong support for clinical decision-making.

Short-term and long-term outcomes of single-incision plus one-port laparoscopic surgery for colorectal cancer: a propensity-matched cohort study with conventional laparoscopic surgery

BACKGROUND

Single-incision plus one-port laparoscopic surgery (SILS + 1) has been demonstrated to be minimally invasive while possessing better cosmesis and less pain compared with conventional laparoscopic surgery (CLS). However, SILS + 1 as an alternative to CLS for colorectal cancer is still controversial.

METHODS

A total of 1071 patients who underwent curative laparoscopic surgery for colon cancer between 2015 and 2018 were included. Of these patients, 258 SILS + 1 cases and 516 CLS cases were analyzed using propensity score matching. The baseline characteristics, surgical outcomes, pathologic findings and recovery course, morbidity and mortality within postoperative 30 days and 3-year disease-free and overall survival were compared.

RESULTS

Baseline characteristics were balanced between the groups. The mean operating time was significantly shorter in SILS + 1 group, with less estimated blood loss. Tumor size, tumor differentiation, number of harvested lymph nodes, resection margin and pathologic T, N, TNM stage was similar between the groups. There was no significant difference in overall perioperative complications. Uni- and multivariate analyses revealed that SILS + 1 was not a risk factor for complications. Postoperatively, SILS + 1 group showed faster recovery than CLS group in terms of ambulation, bowel function, oral intake and discharge. The 3-year disease-free survival rates of SILS + 1 and CLS groups were 90.1% and 87.3%(p = 0.59), respectively and the 3-year overall survival rates were 93.3% vs. 89.8%(p = 0.172).

DISCUSSION

Our study revealed that SILS + 1 is safe, feasible, oncologically efficient, and may be considered as a surgical option for selected patients with colorectal cancer.

Short-term outcomes of single-incision robotic colectomy versus conventional multiport laparoscopic colectomy for colon cancer

Since the da Vinci SP (dVSP) surgical system was introduced, single-incision robotic surgery (SIRS) for colorectal diseases has gained increasing acceptance. Comparison of the short-term outcomes between SIRS using dVSP and those of conventional multiport laparoscopic surgery (CMLS) was performed to verify its efficacy and safety in colon cancer. The medical records of 237 patients who underwent curative resection for colon cancer by a single surgeon were retrospectively reviewed. Patients were divided into two groups according to surgical modality: SIRS (RS group) and CMLS (LS group). Intra- and postoperative outcomes were analyzed. Of the 237 patients, 140 were included in the analysis. Patients in the RS group (n = 43) were predominantly female, younger, and had better general performance than those in the LS group (n = 97). The total operation time was longer in the RS group than in the LS group (232.8 ± 46.0 vs. 204.1 ± 41.7 min, P < 0.001). The RS group showed faster first flatus passing (2.5 ± 0.9 vs. 3.1 ± 1.2 days, P = 0.003) and less opioid analgesic requirement (analgesic withdrawal within 3 postoperative days: 37.2% vs. 18.6%, P = 0.018) than the LS group. The RS group showed a higher immediate postoperative albumin level (3.9 ± 0.3 vs. 3.6 ± 0.4 g/dL, P < 0.001) and lower C-reactive protein level (6.6 ± 5.2 vs. 9.3 ± 5.5 mg/dL, P = 0.007) than the LS group during the postoperative period. On multivariate analysis after adjusting for deviated patient characteristics, no significant difference was observed in short-term outcomes, except for operation time. SIRS with dVSP showed short-term outcomes comparable with those of CMLS for colon cancer.

Single-incision laparoscopic surgery for intestinal intussusception due to neuroendocrine tumor

BACKGROUND

Small intestinal neuroendocrine tumor (NET) is uncommon, but intestinal intussusception caused by NET is even rare. We report a rare case of single-incision laparoscopic surgery (SILS) for intestinal intussusception due to NET G1.

CASE PRESENTATION

A 72-year-old woman presented with vomiting, diarrhea, and abdominal pain. Contrast-enhanced computed tomography (CT) revealed the target sign in the ascending colon. An enhanced nodule was detected at the lead point, leading us to suspect a tumor. Colonoscopy showed a tumor at the lead point of the intestinal intussusception. Histological findings led to a diagnosis of NET G1. Single-incision laparoscopic ileocecal resection with regional lymphadenectomy was then performed. The patient was discharged 10 days postoperatively with no complications.

CONCLUSION

We achieved SILS with regional lymphadenectomy for preoperatively diagnosed intestinal intussusception due to NET G1. Although this condition is rare, surgeons should take this possibility into consideration in cases showing similar findings.

Comparison of robotic reduced-port and laparoscopic approaches for left-sided colorectal cancer surgery

BACKGROUND/OBJECTIVE

The reduced-port approach can overcome the limitations of single-incision laparoscopic surgery while maintaining its advantages. Here, we compared the effects of robotic reduced-port surgery and conventional laparoscopic approaches for left-sided colorectal cancer.

METHODS

Between January 2015 and December 2016, the clinicopathological characteristics and treatment outcomes of 17 patients undergoing robotic reduced-port surgery and 49 patients undergoing laparoscopic surgery for left-sided colorectal cancer were compared.

RESULTS

The two groups were comparable in almost all outcome measures except for the distal resection margin, which was significantly longer in the laparoscopic group (P < 0.001). The between-group differences in reoperation, incisional hernia development, and overall and progression-free survival were nonsignificant; however, the total hospital cost was significantly higher in the robotic group than in the laparoscopic group (US$13779.6 ± US$3114.8 vs. US$8556.3 ± US$2056.7, P < 0.001).

CONCLUSION

Robotic reduced-port surgery for left-sided colorectal cancer is safe and effective but more expensive with no additional benefit compared with the conventional laparoscopic approach. This observation warrants further evaluation.

Clinical outcomes of single incision laparoscopic surgery for colorectal cancer: A propensity score-matched analysis between well-experienced and novice surgeons

Background

Single incision laparoscopic surgery (SILS) is a recent advancement in minimally invasive techniques for colorectal cancer (CRC). However, SILS is a technically challenging procedure for novice surgeons. The aim of this study was to evaluate clinical outcomes of SILS for CRC performed by novice surgeons compared with those performed by well-experienced surgeons.

Methods

We retrospectively analyzed 1004 consecutive patients with stage I-IV CRC who underwent SILS between May 2009 and December 2018, using propensity score-matched analysis.

Results

After propensity score-matching, we enrolled 344 patients (n = 172 in each group). Before matching, significant group-dependent differences were observed in terms of age (P = 0.034) and tumor location (P < 0.001). After matching, preoperative clinical factors were similar between groups, but operative time was longer in the Novice group (213 vs 171 min, P < 0.001). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the Novice group (23 vs 25, P = 0.040), and the number of patients with lymph node metastases was smaller in the Novice group (57 vs 86, P = 0.002). The 3-year disease-free survival rate was 85.8% in the Novice group and 89.9% in the Experienced group (P = 0.512). Three-year overall survival rate was 92.2% in the Novice group and 90.0% in the Experienced group (P = 0.899).

Conclusion

SILS for CRC was safely performed by novice surgeons under the guidance of well-experienced surgeons, and could provide satisfactory oncological outcomes.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for descending colon cancer: a propensity score-matched analysis

BACKGROUND

The clinical impact of single-incision laparoscopic surgery (SILS) for descending colon cancer (DCC) is unclear. The aim of this study was to evaluate the clinical outcomes of SILS for DCC compared with multi-port laparoscopic surgery (MPLS).

METHODS

We retrospectively analyzed 137 consecutive patients with stage I-III DCC who underwent SILS or MPLS at two high-volume multidisciplinary tertiary hospitals between April 2008 and December 2018, using propensity score-matched analysis.

RESULTS

After propensity score-matching, we enrolled 88 patients (n = 44 in each group). SILS was successful in 97.7% of the matched cohort. Compared with the MPLS group, the SILS group showed significantly less blood loss and a greater number of harvested lymph nodes. Morbidity rates were similar between groups. Recurrence pattern did not differ between groups. No significant differences were found between groups in terms of 3-year disease-free and overall survivals.

CONCLUSION

SILS appears safe and feasible and can provide satisfactory oncological outcomes for patients with DCC.

Oncologic outcomes of single-incision laparoscopic surgery versus conventional laparoscopic surgery for colorectal cancer (CSILS): study protocol for a multicentre, prospective, open-label, noninferiority, randomized controlled trial

Background

In most previous studies, single-incision laparoscopic surgery (SILS) for colorectal cancer (CRC) was feasible and safe in the short term. However, long-term oncologic outcomes remain uncertain, as only a few studies contained long-term survival data. SILS for CRC is still in the early stages of research. Further studies, particularly large-scale, prospective randomized controlled trials, are necessary to assess the value of SILS for CRC.

Methods

This study is a prospective, multicentre, open-label, noninferiority, parallel-group randomized controlled trial that investigates the long-term oncologic outcomes of SILS compared to conventional laparoscopic surgery (CLS) for CRC. A total of 710 eligible patients will be randomly assigned to the SILS group or the CLS group at a 1:1 ratio using a central, dynamic, and stratified block randomization method. Patients with ages ranging from 18 to 85 years old, of both sexes, with CRC above the peritoneal reflection diagnosed as cT1-4aN0-2M0 and a tumour size no larger than 5 cm will be considered for the study. The primary endpoint is 3-year disease-free survival (DFS). The secondary endpoints include: intraoperative outcomes, postoperative recovery, postoperative pain assessment, pathological outcomes, early morbidity and mortality rate, cosmetic effects, quality of life, 3-year overall survival (OS), incidence of incisional hernia, 5-year DFS and 5-year OS. The first two follow-up visits will be scheduled at one month and three months postoperatively, then every three months for the first two years and every six months for the next three years.

Discussion

Currently, no randomized controlled trials (RCTs) have been designed to investigate the long-term oncologic outcomes of SILS for CRC. This study is expected to provide clinical evidence of the oncologic outcomes of SILS compared to CLS for CRC to promote its widespread use.

Trial registration

ClinicalTrials.gov: NCT 04527861 (registered on August 27, 2020).

Short- and long-term outcomes of single-incision laparoscopic surgery for right colon cancer: A multicenter propensity score-matched analysis

INTRODUCTION

Single-incision laparoscopic surgery (SILS) for colon cancer is a recent innovation in minimally invasive surgery that can improve short-term outcome. However, several biases exist in current favorable comparisons of SILS with conventional laparoscopic (CL) surgery. Moreover, the oncological outcomes in SILS remain unclear. The aim of this study was to identify outcomes following SILS and CL for right colectomy using a propensity score-matched analysis.

METHODS

A total of 553 patients underwent curative resection for right colon cancer (58 SILS and 495 CL). After propensity score matching, 58 patients in each group were matched.

RESULTS

Before matching, median age was younger (p = 0.037) and clinical stage was lower (p < 0.001) in the SILS group. After matching, operation time was shorter (172 versus 193 min, p = 0.007) and blood loss was less (12 versus 20 mL, p = 0.037) in the SILS group. Most of the SILS cases were performed (43.1%) or supervised (51.7%) by an expert surgeon. Median follow-up duration was 30 and 37 mo in the SILS and CL groups, respectively. Three-year relapse-free survival was 92.5% and 92.4% (p = 0.781); and overall survival was 100% versus 98.1% (p = 0.177).

CONCLUSIONS

Under the control of expert surgeons, SILS appeared to be a safe and feasible approach and had similar oncological outcomes compared with CL in a propensity score-matched cohort of patients with right-sided colon cancer.

Comparison of clinical outcomes of single-incision versus multi-port laparoscopic surgery for rectosigmoid or upper rectal cancer

BACKGROUND

Single-incision laparoscopic surgery (SILS) for rectal cancer is technically challenging, and its clinical impact is unclear. The aim of this study was to evaluate clinical outcomes of SILS for rectal cancer compared with multi-port laparoscopic surgery (MPLS).

PATIENTS AND METHODS

We retrospectively analyzed 357 consecutive patients with stage I-III rectal cancer located in the rectosigmoid or upper rectum who underwent SILS or MPLS between January 2012 and December 2016, using propensity score-matched analysis.

RESULTS

After propensity score-matching, we enrolled 204 patients (n = 102 per group). Before matching, significant group-dependent differences were observed in tumor location (p < 0.001). After matching, preoperative clinical factors were similar between groups. SILS was successful in 73.5% of cases, an additional port was required in 23.5%, and 2.9% were converted to open surgery. Compared to the MPLS group, the SILS group showed shorter operative time (192 vs. 211 min, p = 0.015) and shorter postoperative hospital stay (9 vs. 11 days, p = 0.038). Other operative factors and morbidity rates did not differ significantly between groups. The number of harvested lymph nodes was smaller in the SILS group (24) than in the MPLS group (27, p = 0.008). Postoperative recurrence did not differ between groups, either before or after matching. No significant differences in 3-year disease-free, 3-year local recurrence-free, or 5-year overall survival were found between groups.

CONCLUSIONS

SILS is safe, is feasible, and offers satisfactory oncological outcomes in selected patients with rectosigmoid or upper rectal cancer.

Short-Term Outcomes of Single-Incision Laparoscopic Surgery for Colorectal Cancer: A Single-Center, Open-Label, Non-Inferiority, Randomized Clinical Trial

Objective

To date, well-designed randomized controlled trials examining the safety, efficacy, and long-term outcomes of single-incision laparoscopic surgery (SILS) for colorectal cancer are scarce. The aim of the current study was to compare short-term outcomes of SILS for colorectal cancer with conventional laparoscopic surgery (CLS).

Methods

Between June 28, 2017, and June 29, 2019, a single-center, open-label, non-inferiority, randomized clinical trial was conducted at the Department of General Surgery, Ruijin Hospital (North), Shanghai Jiaotong University School of Medicine in Shanghai, China. In total, 200 patients diagnosed or suspected of colorectal cancer (cT_1-4aN_0-2M₀) were randomly assigned to either the SILS or CLS group in a 1:1 ratio. The primary outcome was early morbidity rate. Secondary outcomes included intraoperative outcomes, pain intensity, postoperative recovery, pathologic outcomes, and long-term outcomes.

Results

In total, 193 participants (SILS, 97; CLS, 96) were analyzed in the modified intention-to-treat (MITT) population. Among them, 48 underwent right hemicolectomy (SILS n = 23, 23.7% and MLS n = 25, 26%), 15 underwent left hemicolectomy (SILS n = 6, 6.2% and MLS n = 9, 9.4%), 1 underwent transverse colectomy (MLS n = 1, 1%), 57 underwent sigmoidectomy (SILS n = 32, 33% and MLS n = 25, 26%), and 72 underwent anterior resection (SILS n = 36, 37.1% and MLS n = 36, 37.5%). No significant differences were observed in the baseline characteristics. The intraoperative complication was comparable between the two groups [5 (5.2%) vs. 4 (4.2%); difference, 1%; 95% CI, -5.8% to 7.8%; p > 0.999) and so was postoperative complication rates [10 (10.3%) vs. 14 (14.6%); difference, -4.3%; 95% CI, -13.9% to 5.3%; p = 0.392]. The SILS group showed shorter incision length [median (IQR), 4 (3.5-5) vs. 6.6 (6-7.5), p < 0.001] and lower VAS scores on the first [median (IQR), 4 (3-5) vs. 4 (4-5), p = 0.002] and the second day [median (IQR), 2 (1.5-3) vs. 3 (2-4), p < 0.001] after surgery. No statistically significant difference was found in other measured outcomes.

Conclusions

Compared with CLS, SILS performed by experienced surgeons for selected colorectal cancer patients is non-inferior with good short-term safety and has the advantage of reducing postoperative pain.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT03151733.

Long-term oncologic outcomes of single-incision laparoscopic surgery for colon cancer

BACKGROUND

Studies find similar perioperative outcomes between single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for colon cancer. However, few have reported long-term outcomes of SILS versus CLS. We aimed to compare long-term postoperative and oncologic outcomes as well as perioperative outcomes between SILS and CLS for colon cancer.

METHODS

A total of 641 consecutive patients who underwent laparoscopic surgery for colon cancer from July 2009 to September 2014 were eligible for the study. Data from 300 of these patients were used for analysis after propensity score-matching (n = 150 per group). Variables associated with short- and long-term outcomes were analyzed.

RESULTS

The SILS group had a shorter mean total incision length, less postoperative pain, and a similar mean rate of incisional hernia (2.7% versus 3.3%) compared with the CLS group. The 7-year overall and disease-free survival rates were 92.7% versus 94% (p = 0.673) and 85.3% versus 84.7% (p = 0.688) in the SILS and CLS groups, respectively.

CONCLUSIONS

Compared with CLS, SILS for colon cancer appeared to be safe in terms of perioperative and long-term postoperative and oncologic outcomes. The results suggested that SILS is a reasonable treatment option for colon cancer for a selected group of patients.

Long-term Outcomes of a Randomized Controlled Trial of Single-incision Versus Multi-port Laparoscopic Colectomy for Colon Cancer

OBJECTIVE

The aim of this study was to evaluate the long-term outcomes that were the secondary endpoints of a RCT of multi-port laparoscopic colectomy (MPC) versus SILC in colon cancer surgery.

SUMMARY OF BACKGROUND DATA

The actual long-term outcomes, such as the 5-year RFS, OS, and recurrence patterns after surgery, have not been evaluated by a RCT.

METHODS

Patients with histologically proven colon carcinoma located in the cecum, ascending, sigmoid or rectosigmoid colon clinically diagnosed as stage 0-III were eligible for this study. Patients were preoperatively randomized and underwent complete mesocolic excision. The 5-year RFS, OS, and recurrence patterns were analyzed (UMIN-CTR 000007220).

RESULTS

Between March 1, 2012, and March 31, 2015, a total of 200 patients were randomly assigned to either the MPC arm (n = 100) or SILC arm (n = 100). The median follow-up for all patients was 61.0 months. An intention-to-treat analysis showed that the 5-year RFS was 91.0% [95% confidence interval (CI) 85.1%-96.9%] in the MPC arm and 88.0% (95% CI 82.1%-93.9%) in the SILC arm (hazard ratio: 1.37; 95% CI 0.58-3.24; P = 0.479). The 5-year OS was 95.0% (95% CI 91.1%-98.9%) in the MPC arm and 93.0% (87.1%-98.9%) in the SILC arm (hazard ratio: 1.39; 95% CI 0.44-4.39; P = 0.568). There were no significant differences in the recurrence patterns between the 2 arms.

CONCLUSIONS

Even though the results of the 5-year OS and RFS in this trial were exploratory and underpowered, there were no statistically significant differences between the SILC and MPC arms. SILC may be an acceptable treatment option for select patients with colon cancer.

Single-incision versus conventional multiport laparoscopic surgery for colorectal cancer: a meta-analysis of randomized controlled trials and propensity-score matched studies

PURPOSE

To compare single-incision laparoscopic surgery (SILS) and multiport laparoscopic surgery (MLS) for colorectal cancer in terms of short- and long-term outcomes.

METHODS

A systematic literature search was performed in PubMed, Web of Science, and Embase. Randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing SILS and MLS for colorectal cancer were enrolled. Outcomes of interests included intraoperative, postoperative, pathological, and survival outcomes.

RESULTS

Sixteen studies (6 RCTs and 10 PSM studies) published between 2012 and 2020 with a total of 2425 patients were enrolled. Compared with MLS, SILS was associated with less postoperative pain at postoperative day (POD) 1 (P = 0.02, MWD = -0.73, 95%CI: -1.37, -0.09) and POD2 (P < 0.001, MWD= -1.10, 95%CI: -1.45, -0.74) and shorter length of total incision length (P < 0.001, MWD = -3.31, 95%CI: -3.95, -2.67). No differences were observed in terms of operative time, blood loss, intraoperative and postoperative complications, incision hernia, and pathological or survival outcomes between SILS and MLS. Subgroup analysis for right-sided colon cancer, sigmoid colon cancer, and rectosigmoid colon cancer showed that the SILS group was only associated with less postoperative pain and shorter total incision length. The surgical and pathological outcomes were comparable between SILS and MLS.

CONCLUSIONS

SILS is a beneficial alternative to MLS in select colorectal cancer patients, especially for right-sided colon cancer, sigmoid colon cancer, and rectosigmoid cancer, with better cosmetic effects and less postoperative pain. Simultaneously, SILS does not compromise intraoperative and postoperative complications, surgical quality, or long-term outcomes.

Long-term outcomes of single-incision versus multiport laparoscopic colectomy for colon cancer: results of a propensity score-based analysis

BACKGROUND

Long-term outcomes of single-incision laparoscopic colectomy (SILC) for colon cancer (CC), as practiced in real-world settings, especially in relation to disease stage, have not been established. We examined, retrospectively, both short- and long-term outcomes of SILC versus those of multiport laparoscopic colectomy (MPLC) performed for CC in a propensity-score-matched cohort.

METHODS

The study involved 263 patient pairs matched 1:1 from among 691 patients who, between January 2008 and May 2014, underwent either SILC or MPLC for a primary solitary CC at our hospital. Short-term and long-term operative outcomes were compared between the two groups.

RESULTS

Operation time was the only surgical outcome that varied significantly between the two groups (p = 0.0004). Overall 5-year cancer-specific survival (CSS) in the SILC group was 93.7 (95% CI 89.6-96.2)%, and CSS per pathological stage (I, II and III) was 98.5 (90.0-99.8)%, 96.0 (88.2-98.7)%, and 88.3 (79.6-93.6)%, respectively, whereas overall 5-year CSS in the MPLC group was 93.3 (89.4-95.9)%, and CSS per pathological stage was 100%, 95.4 (88.3-98.3)%, and 84.1 (74.1-90.8)% (p = 0.5278, 0.2679, 0.7666, and 0.9073), respectively. Overall 3-year disease-free survival (DFS) in the SILC group was 94.0 (90.2-96.4)%, and 3-year DFS per pathological stage was 98.6 (90.4-99.8)%, 90.1 (81.4-95.0)%, and 79.0 (69.4-86.2)%, respectively, whereas overall 3-year DFS in the MPLC group was 93.2 (89.4-95.7)%, and 3-year DFS per pathological disease stage was 100%, 94.5 (87.4-97.7)% and 75.5 (64.7-83.8)% (p = 0.2829, 0.7401, 0.4335 and 0.8518), respectively. Thus, oncological outcomes did not differ significantly between groups. Incisional hernia occurred in 21 (8.0%) SILC group patients and 17 (6.5%) MPLC group patients, without a significant between-group difference (p = 0.6139).

CONCLUSION

Our data indicate that perioperative and oncological outcomes of SILC performed for CC are comparable to those of MPLC performed for CC.

Short-term Outcomes of Single-port Versus Multiport Laparoscopic Surgery for Colon Cancer: The SIMPLE Multicenter Randomized Clinical Trial

OBJECTIVE

To compare short-term perioperative outcomes of single-port laparoscopic surgery (SPLS) and multiport laparoscopic surgery (MPLS) for colon cancer.

SUMMARY BACKGROUND DATA

Although many studies reported short- and long-term outcomes of SPLS for colon cancer compared with MPLS, few have reported results of randomized controlled trials.

METHODS

This was a multicenter, prospective, randomized controlled trial with a noninferiority design. It was conducted between August 2011 and June 2017 at 7 sites in Korea. A total of 388 adults (aged 19-85 yrs) with clinical stage I, II, or III adenocarcinoma of the ascending or sigmoid colon were enrolled and randomized. The primary endpoint was 30-day postoperative complication rates. Secondary endpoints were the number of harvested lymph nodes, length of the resection margin, postoperative pain, and time to functional recovery (bowel movement and diet). Patients were followed for 30 days after surgery.

RESULTS

Among 388 patients, 359 (92.5%) completed the study (SPLS, n = 179; MPLS, n = 180). The 30-day postoperative complication rate was 10.6% in the SPLS group and 13.9% in the MPLS group (95% confidence interval, -10.05 to 3.05 percentage points; P < 0.0001). Total incision length was shorter in the SPLS group than in the MPLS group (4.6 cm vs 7.2 cm, P < 0.001), whereas the length of the specimen extraction site did not differ (4.4 cm vs 4.6 cm, P = 0.249). There were no significant differences between groups for all secondary endpoints and all other outcomes.

CONCLUSIONS

Even though there was no obvious benefit to SPLS over MPLS when performing colectomy for cancer, our data suggest that SPLS is noninferior to MPLS and can be considered an option in selected patients, when performed by experienced surgeons.Trial registration: ClinicalTrials.gov Identifier: NCT01480128.

Reduced Port Surgery for a Pregnant Woman With Strangulated Small Bowel Obstruction: A Case Report

Introduction

Intestinal obstruction in pregnancy is very rare, but the maternal mortality rate and the fetal loss rate are high. Therefore, an early diagnosis and appropriate treatments for small bowel obstructions (SBOs) during pregnancy are crucial for the mothers and fetuses. On the other hand, laparoscopic surgeries are widely used in pregnant patients, although laparoscopic surgeries for SBOs can have higher risks of complications. Then, reduced port surgery (RPS) can reduce the risk of intestinal injury by minimizing the number of ports the operator could not control alone. There is no previous report of RPS for SBOs in pregnant patients. We report on a pregnant patient with a strangulated SBO treated with RPS without complications.

Case presentation

A 37-year-old Japanese pregnant woman complaining of severe abdominal pain was admitted by ambulance. Her gestational age was 9 weeks. Her medical history included surgery for acute perforated appendicitis and deep vein thrombosis due to anti-thrombin III deficiency. Abdominal computed tomography revealed a strangulated SBO. We performed RPS and the cause of strangulated SBO was a string at the postoperative site of the appendectomy. The ischemic region of the small bowel recovered after we cut the string and released the adhesion. The patient's postoperative course was uneventful and the fetus was not harmed.

Conclusion

This is the first report of RPS performed for the pregnant patient with the strangulated SBO. Our findings indicate that RPS is a feasible treatment for strangulated SBOs in pregnant women.

Systematic review of single-port vs. multi-port surgery for rectal cancer

The aim of the current systematic review was to compare the short-term clinical and oncological outcomes of single-port surgery (SPS) to multi-port surgery (MPS) for rectal cancer in MEDLINE, PubMed and Cochrane Library from January 2010 to December 2018. A total of 5 clinical controlled studies composed one randomized pilot study and four non-randomized studies with a total of 461 patients were analyzed after a systematic review. A total of 125 patients (27.1%) underwent SPS and 336 patients (72.9%) underwent MPS for rectal cancer. The rate of conversion to open surgery was lower in the SPS group compared with the MPS group (0.8 vs. 5.4%, respectively). A total of 16.8% of patients in the SPS group required an additional port to complete the operation. The morbidity rate was lower in the SPS group compared with the MPS group (28.0 vs. 39.0%, respectively). The other short-term clinical outcomes were similar in both groups. The R0 resection rate was 99.0% in the SPS group and 98.7% in the MPS group. The oncological clearance was satisfactory and similar in both groups. The current study concluded that SPS can be performed safely and provide satisfactory oncological outcomes in patients with rectal cancer. However, further studies are required to determine the role of SPS in the long-term clinical and oncological outcomes.

Effects of needlescopic surgery on postoperative pain in intersphincteric or abdominoperineal resection

PURPOSE

Laparoscopic surgery allows minimally invasive treatment of rectal cancer, and needlescopic surgery (NS) offers even more minimally invasive operations beyond the scope of conventional laparoscopic surgery (CS). The aim of this study was to compare short-term outcomes of NS for intersphincteric resection (ISR) or abdominoperineal resection (APR) to treat anal or rectal cancer without an abdominal incision for specimen extraction and to measure abdominal wound pain compared to CS.

METHODS

Between September 2014 and December 2016, a total of 134 patients underwent laparoscopic ISR or APR. Of these, 26 patients underwent NS, and 108 patients underwent CS. Postoperative abdominal wound pain was estimated using the numerical rating scale. Short-term outcomes were compared between NS and CS.

RESULTS

No conversion to CS or open surgery was required. Median operation time was significantly shorter with NS (295 min) than with CS (331.5 min; p = 0.020). Median estimated blood loss was significantly lower with NS (30 ml) than with CS (50 ml; p = 0.011). Postoperative pain score on postoperative day (POD)5 was significantly lower with NS than with CS (p = 0.025), and frequencies of analgesic use were significantly lower with NS than with CS on POD0, POD2, and POD3 (p = 0.032, p = 0.017, p = 0.045, respectively). The postoperative complications occurred at similar frequencies between groups (p = 0.655).

CONCLUSION

NS for ISR or APR offers comparable short-term outcomes to CS, with better pain outcomes.

Feasibility of Single-Incision Plus One Port Laparoscopic Low Anterior Resection for Rectal Cancer

PURPOSE

Single-incision laparoscopic surgery is a recently developed minimally invasive surgical technique. We aimed to compare the feasibility and safety of single-incision plus one port laparoscopic low anterior resection (S+1-LAR) with those of multi-port laparoscopic low anterior resection (M-LAR) for mid-to-low rectal cancer.

METHODS

We retrospectively reviewed patient characteristics and surgical outcomes by assessing data collected from the medical records of patients who underwent elective laparoscopic low anterior resection for mid-to-low rectal cancer at the Gangneung Asan Hospital.

RESULTS

From April 2015 to April 2019, 52 patients underwent S+1-LAR (n=28) or M-LAR (n=24) for mid-to-low rectal cancer at Gangneung Asan Hospital. There were no significant between-group differences in clinical characteristics. The mean postoperative 1-day pain score was significantly lower in the S+1-LAR group. Surgical outcomes and postoperative complications did not differ significantly between the two groups.

CONCLUSION

S+1-LAR is a feasible and safe technique and is comparable with M-LAR in terms of surgical outcomes of patients with mid-to-low rectal cancer.

Long-term and short-term surgical outcomes of single-incision laparoscopic hepatectomy on anterolateral liver segments

BACKGROUND

Laparoscopic liver resection yields improved short-term surgical outcomes, whereas the reports about clinical benefits of single-incision laparoscopic hepatectomy (SILH) are scarce. This retrospective study is to compare the surgical outcomes of SILH with those of multi-incision laparoscopic hepatectomy (MILH).

METHODS

The study included 54 patients who had undergone SILH and 184 patients who had undergone MILH between January 2010 and December 2017. Short-term outcomes were compared in those of patients who underwent left lateral sectionectomy and partial hepatectomy of segment 5-6. A subgroup analysis of hepatocellular carcinoma (HCC) was also performed for long-term outcome comparisons.

RESULTS

In those of patients who underwent left lateral sectionectomy, SILH group had less chronic hepatitis B (15.2 vs. 45.8%; p = 0.004), less liver cirrhosis (12.1 vs. 50.0%; p = 0.002), less tumor proximal to major vessel (6.1 vs. 29.2%; p = 0.018), shorter surgical time (113.2 ± 37.9 vs. 146.0 ± 50.5 min; p = 0.007), and shorter postoperative hospital stays (4.4 ± 1.1 vs. 5.4 ± 1.3 days; p = 0.002) compared with MILH group. In those of patients with tumor located at segment 5-6, no significant differences were observed in surgical time, blood loss, complications, and mortality. Single-incision laparoscopic partial hepatectomy was only associated with wider surgical margins (11.8 ± 7.0 vs. 5.3 ± 5.2 mm; p = 0.003). In the HCC subgroup, SILH had similar 1-, 3-, and 5-year overall survival and 1-, 3-, and 5-year recurrence-free survival rates compared with patients who had undergone MILH.

CONCLUSIONS

The study demonstrates the safety and feasibility of single-incision laparoscopic liver resection for left lateral sectionectomy and partial hepatectomy for segment 5-6. In selected patients within the group and by experienced surgical team, the SILH technique results in comparable short-term surgical outcomes and long-term oncological outcomes.

Hernia incidence following a randomized clinical trial of single-incision versus multi-port laparoscopic colectomy

BACKGROUND

The short-term results of single-incision laparoscopic colectomy (SILC) showed the safety, feasibility, and effectiveness when performed by skilled laparoscopic surgeons. However, the long-term complications, such as SILC-associated incisional hernia, have not been evaluated. The aim of this study was to determine the incidence of incisional hernia after SILC compared with multi-port laparoscopic colectomy (MPC) for colon cancer.

METHODS

From March 2012, to March 2015, a total of 200 patients were enrolled in this study. The patients were randomized to the MPC arm and SILC arm. A total of 200 patients (MPC arm; 100 patients, SILC arm; 100 patients) were therefore analyzed. In all cases the specimen was extracted through the umbilical port, which was extended according to the size of the specimen. A diagnosis of incisional hernia was made either based on a physical examination or computed tomography.

RESULTS

The baseline factors were well balanced between the arms. The median follow-up period was 42.4 (range 9.4-70.0) months. Twenty-one patients were diagnosed with incisional hernia, giving an incidence rate of 12.1% in the MPC arm and 9.0% in the SILC arm at 36 months (P = 0.451). In the multivariate analysis, the body mass index (≥ 25 kg/m²) (hazard ratio [HR] 3.03; 95% confidence interval [CI] 1.03-8.92; P = 0.044), umbilical incision (≥ 5.0 cm) (HR 3.22; 95% CI 1.16-8.93; P = 0.025), and history of umbilical hernia (HR 3.16; 95% CI 1.02-9.77; P = 0.045) were shown to be correlated with incisional hernia.

CONCLUSIONS

We found no significant difference in the incidence of incisional hernia after SILC arm versus MPC arm with a long-term follow-up. However, this result may be biased because all specimens were harvested through the umbilical port. The study was registered with the Japanese Clinical Trials Registry as UMIN000007220.

Clinical and oncological outcomes of single-incision vs. conventional laparoscopic surgery for rectal cancer

BACKGROUND

To evaluate the clinical and oncological outcomes of single-incision laparoscopic surgery (SILS) vs. conventional laparoscopic surgery (CLS) for patients with rectal cancer (RC) who underwent total mesorectal excision (TME) surgery.

METHODS

This was a retrospective case-control study of patients with RC operated between 12/2013 and 12/2017 in Ruijin Hospital North, Shanghai Jiaotong University School of Medicine. In total, 177 patients who underwent CLS and 51 who underwent SILS met the inclusion and exclusion criteria and were matched 1:1 using propensity score matching method (PSM).

RESULTS

Compared with the CLS group, the SILS group showed shorter operation time [105 (40) vs. 125 (55) min, P = 0.045], shorter total incision length [4 (1) vs. 6.5 (1.5) cm, P < 0.001], lower VAS score on POD2 [1 (1) vs. 2 (1), P < 0.001], shorter time to soft diet [7 (1) vs. 8 (2) days, P = 0.048], and shorter length of hospital stay [9 (2) vs. 11 (3) days, P < 0.001]. The postoperative complications were similar between two groups [1(2%) vs. 5 (9.8%), P = 0.205]. No readmissions or mortality in either group occurred within 30 days of surgery. All 102 specimens met the requirements of TME. No significant differences were observed in the pathologic outcomes between the two groups. The median follow-up period was 32.6 months in the SILS group and 36.8 months in the CLS group (P = 0.053). The 3-year disease-free survival rates and overall survival rates of the SILS and CLS groups were 89.8% vs. 96.0% (P = 0.224) and 90.9% vs. 96.9% (P = 0.146), respectively.

CONCLUSIONS

Compared with CLS, TME surgery for rectal cancer can be performed safely and effectively using the SILS technique with better cosmetic results, less postoperative pain, faster postoperative recovery, and acceptable clinical and oncological outcomes.

Pure transanal total mesorectal excision for rectal cancer: experience with 55 cases

Background

Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision (h-taTME), a completely incisionless surgical procedure has not yet been developed. This study was performed to explore the efficacy of pure taTME (p-taTME) without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer.

Methods

We retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018. Relevant patient characteristics and clinical information including the surgical procedure, specimens, pathological characteristics, and patients’ post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed.

Results

Fifty-five patients who had undergone p-taTME were included in this study. They comprised 32 (58.2%) men and 23 (41.8%) women with a mean age of 65.6 ± 10.6 years and mean body mass index of 23.4 ± 3.3 kg/m². The median surgical time was 180.0 (range, 130–360) min and estimated blood loss was 25.0 (range, 15–80) mL. The commonest post-operative complication was varying degrees of faecal incontinence (56.4%). However, such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’ quality of life.

Conclusions

p-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer, especially in those with obesity or a narrow pelvis. However, further studies of the indications and long-term efficacy are needed to verify the suitability of this procedure.

Impact of single-incision laparoscopic surgery on postoperative analgesia requirements after total colectomy for ulcerative colitis: a propensity-matched comparison with multiport laparoscopy

AIM

To compare the requirements for postoperative analgesia in patients with ulcerative colitis after single-incision versus multiport laparoscopic total colectomy.

METHOD

All patients undergoing single-incision or multiport laparoscopic total colectomy as a first stage in the surgical treatment of ulcerative colitis between 2010 and 2016 at the University Hospital of Leuven were included. The cumulative dose of postoperative patient-controlled analgesia was used as the primary end-point. A Z-transformation was performed combining values for patient-controlled epidural analgesia and patient-controlled intravenous analgesia, resulting in one hybrid outcome variable. The two groups were matched using propensity scores. Subgroup analysis was performed to analyse the impact of extraction site on postoperative pain.

RESULTS

A total of 81 patients underwent total colectomy for ulcerative colitis (median age 35 years). Thirty patients underwent single-incision laparoscopy, while 51 patients had a multiport approach. The mean normalized patient-controlled analgesia dose was significantly lower in patients undergoing single-incision laparoscopy (-0.33 vs 0.46, P < 0.001). This difference was no longer significant in subgroup analysis for patients with stoma site specimen extraction (P = 0.131). The odds of receiving tramadol postoperatively was 3.66 times lower after single-incision laparoscopy (P = 0.008). The overall morbidity rate was 32.1% (26/81). The mean Comprehensive Complication Index in single-incision and multiport laparoscopy group was 18.33 and 21.39, respectively (P = 0.506). Hospital stay was significantly shorter after single-incision laparoscopic surgery (6.3 days vs 7.6 days, P = 0.032).

CONCLUSION

Single-incision total colectomy was associated with lower postoperative analgesia requirements and shorter hospital stay, with comparable morbidity. However, the specimen extraction site played a significant role in postoperative pain control.

Long-term oncological outcomes of single-port laparoscopic surgery for colon cancer

BACKGROUND

We retrospectively reviewed our consecutive experience from the introduction of single-port laparoscopic surgery (SPS) for colon cancer, and its 5-year oncological outcomes are evaluated.

METHODS

A total of 288 patients (140 males) with a mean age of 71.5 years were treated with the single-port laparoscopic colectomy for stage I, II and III colon cancers. Exclusion criteria of SPS were patients with unresolved bowel obstruction, T4b tumour, tumour perforation and severe medical illness.

RESULTS

In 20 patients (6.9%), we inserted an extra port mainly to transect the rectum. The median follow-up period was 52 months. The 5-year relapse-free survival rates in stage I, II and III patients were 95.8%, 80.2% and 61.6%, respectively. The 5-year overall survival rates for stage I, II and III patients were 97.4%, 85.3% and 72.9%, respectively. The 5-year cancer-specific survival rates in patients diagnosed pathologically T1, T2, T3 and T4 were 100%, 100%, 92.1% and 73.9%, respectively.

CONCLUSIONS

SPS colectomy can be applied to the treatment of colon cancer with good long-term oncological outcomes. However, we should pay more attention when we treat the pathologically diagnosed T4 tumours.

Short-term outcomes of single-incision plus one-port laparoscopic versus conventional laparoscopic surgery for rectosigmoid cancer: a randomized controlled trial

OBJECTIVE

The objective of the study is to evaluate the short-term outcomes of single-incision plus one-port surgery (SILS + 1) compared with conventional laparoscopic surgery (CLS) for colonic cancer.

BACKGROUND

At present, single-incision laparoscopic colectomy remains technically challenging. The use of SILS + 1 as an alternative has gained increasing attention; however, its safety and efficacy remain controversial.

METHODS AND PATIENTS

Between April 2014 and July 2016, 198 patients with clinical stage T1-4aN0-2 M0 rectosigmoid cancer were enrolled. The participants were randomly assigned to either SILS + 1 (n = 99) or CLS (n = 99). The morbidity and mortality within 30 days, operative and pathologic outcomes, postoperative recovery course, inflammation and immune responses, and pain intensity were compared.

RESULTS

There was no significant difference in overall complications between the two groups (17.2 vs. 16.3%, P = 1.000). The total operating time for the SILS + 1 group was significantly shorter (100.8 ± 30.4 vs. 116.6 ± 36.6, P = 0.002). Blood loss was significantly greater in the CLS group (20 vs. 50, P < 0.001). Thirteen patients (14%) in the CLS group required additional postoperative analgesics, which was significantly more than four patients in the SILS + 1 group. Notably, on postoperative day three, the visual analogue scale score of the CLS group was greater than that of the SILS + 1 group (1.3 ± 1.1 vs. 1.7 ± 1.3, P = 0.023). Tumor diameter, pathologic stage, length of the proximal and distal margins, and number of lymph nodes harvested were similar, other values were also similar between the two groups.

CONCLUSION

Our findings suggest that SILS + 1 might be safe and feasible for rectosigmoid cancer when performed by experienced surgeons. It offers minimal invasiveness without compromising oncologic treatment principles. Trial Registration This trial was registered on ClinicalTrials.gov (NCT02117557).

Clinical impact of single-incision laparoscopic right hemicolectomy with intracorporeal resection for advanced colon cancer: propensity score matching analysis

BACKGROUND

Laparoscopic right hemicolectomy has become an acceptable treatment for right-sided colon cancer. Most centers use multiport laparoscopic right hemicolectomy extracorporeally (MRHE), whereas single-incision laparoscopic right hemicolectomy intracorporeally (SRHI) remains controversial. The aim of this study was to compare these two techniques using propensity score matching analysis.

METHODS

We analyzed the data from 111 patients who underwent laparoscopic right hemicolectomy between December 2015 and December 2016. The propensity score was calculated according to age, gender, body mass index, the American Society of Anesthesiologists score, previous abdominal surgery, and D3 lymph node dissection. Postoperative pain was evaluated using a visual analogue scale (VAS) and postoperative analgesic use was an outcome measure.

RESULTS

The length of skin incision in SRHI was significantly shorter than in MRHE [3 (3.5-6) versus 4 (3-6) cm, respectively; P = 0.007]. The VAS score on day 1 and day 2 after surgery was significantly less in SRHI than in MRHE [30 (10-50) versus 50 (20-69) on day 1, P = 0.037; 10 (0-50) versus 30 (0-70) on day 2, P = 0.029]. Significantly fewer patients required analgesia after SRHI on day 1 and day 2 after surgery [1 (0-3) versus 2 (0-4) on day 1, P = 0.024; 1 (0-2) versus 1 (0-4) on day 2, P = 0.035]. There were no significant differences in operative time, intraoperative blood loss, number of lymph nodes removed, and postoperative course between groups.

CONCLUSIONS

SRHI appears to be safe and technically feasible. Moreover, SRHI reduces the length of the skin incision and postoperative pain compared with MRHE.

Clinical Outcomes of Single-port Surgery for Colon Cancer in Octogenarians

AIM

The aim of this study was to evaluate the clinical outcomes of single-port surgery for colon cancer in octogenarians.

MATERIALS AND METHODS

A retrospective cohort study was performed on patients who underwent single-port surgery for colon cancer from 2010 to 2014 at a single institution. Patients were categorized into the following 3 groups according to age: ≤69 years (n=196), 70 to 79 years (n=143), and ≥80 years (n=86). Short-term and long-term outcomes were assessed among 3 groups.

RESULTS

The rate of overall postoperative complications in the octogenarian group did not differ significantly, compared with the other groups (20.9% in the octogenarians group vs. 14.3% in the ≤69 y group and 15.4% in the 70 to 79 y group, P=0.363). The 3-year relapse-free survival rates were similar among groups (83.9% in the octogenarians group vs. 87.8% in the ≤69 y group and 87.5% in the 70 to 79 y group, P=0.754). The 5-year overall survival rates were 79.8% in the octogenarians group, 89.9% in the ≤69 years group, and 81.7% in the 70 to 79 years group (P=0.063).

CONCLUSION

Single-port surgery is safe, feasible, and can provide satisfactory oncological outcomes in octogenarians with colon cancer.

Clinical and oncologic outcomes of single-incision laparoscopic surgery for right colon cancer: a propensity score matching analysis

BACKGROUND

Single-incision laparoscopic surgery (SILS) for right colon cancer is going to be considered as a new option. The potential benefits, clinical, and oncologic outcomes are still controversial. The aim of this study was to investigate clinical and oncologic outcomes of single-incision laparoscopic surgery (SILS) compared to conventional laparoscopic surgery (CLS) for right colon cancer using propensity score matching analysis.

METHODS

From December 2013 to June 2017, 174 patients underwent laparoscopic radical right hemicolectomy through a single-incision (n = 32) or a conventional (n = 142) approach. The data were prospectively collected and the patients were matched at a radio of 1:1 according to age, sex, body mass index (BMI), previous abdominal surgeries, comorbidities, ASA score (≤ 2/> 2), and pathologic stage.

RESULTS

No significant differences were observed in estimated blood loss, time to diet, postoperative pain score, length of hospital stay between the SILS and CLS groups. However, the SILS group showed longer operation time (175 (40) vs 145 (52.5), p = 0.011) and shorter incision length (4 (1.4) vs 7 (1.9), p < 0.001). There were 2 (6.3%) postoperative complications in the SILS group and 5 (15.6%) in the CLS group (p = 0.426). The pathologic outcomes were similar between two groups. The median follow-up period was 26.5 months in the SILS group and 34.9 months in the CLS group (p = 0.002). There were 3 recurrences (9.4%) in the SILS group and 3 (9.4%) in the CLS group. The 3-year disease-free survival rates were 92.4 and 93.8% (p = 0.984), and overall survival rates were 92.3 and 93.0% (p = 0.884) in the SILS and the CLS groups, respectively. No incisional hernia was observed during the follow-up period.

CONCLUSIONS

Though single-incision laparoscopic surgery for right colon cancer showed longer operation time in this study, it appears to be a safe and feasible option with comparable clinical and oncologic outcomes to conventional laparoscopic surgery.

A rare case of perivascular epithelioid cell tumor (PEComa) of the greater omentum

Background

A tumor composed exclusively or predominantly of human melanin black 45 (HMB45)-positive epithelioid cells is called a perivascular epithelioid cell tumor (PEComa). We report a very rare case of a PEComa of the greater omentum.

Case presentation

MRI conducted to examine the orthopedic disease of the patients, a 49-year-old Japanese woman, also identified a tumor in her pelvis. A CT scan revealed a tumor mass on the right side of the pelvic floor and clear nutrient vessels originating from the splenic and celiac arteries. An omental primary tumor or accessory spleen was thus suspected, and tumor resection was performed. The tumor was a light brown solid tumor with a smooth margin, measuring 5.2 × 3.8 × 3.5 cm. Histopathologically, the tumor was composed mainly of spindle and epithelioid cells, and large and small blood vessel formation was observed. In the immunohistochemical staining, tumor cells were positive for human melanin black 45 (HMB-45) and Melan-A and partially positive for alpha-smooth muscle actin. The final diagnosis was PEComa of the greater omentum.

Conclusions

Although omental PEComa is very rare, it should be considered as a differential disease of an omental primary tumor.

Multidimensional analyses of the learning curve for single-incision plus one port laparoscopic surgery for sigmoid colon and upper rectal cancer

BACKGROUND AND OBJECTIVES

Single-incision plus one port surgery (SILS + 1) provides the advantages of being minimally invasive and easier to perform than pure single-incision laparoscopic surgery. The aim of this study was to investigate the learning curve (LC) for SILS + 1 for sigmoid colon and upper rectal cancer.

METHOD

From November 2012 to May 2014, a series of 85 consecutive patients underwent selective SLIS + 1 for sigmoid colon and upper rectal cancer performed by a single surgeon at Nanfang Hospital. The LC for SILS + 1 was evaluated using cumulative sum control chart (CUSUM) and risk-adjusted CUSUM methods. Data for all the perioperative variables and pathologic results among the phases were compared.

RESULTS

The LC had three phases: phase 1 (cases 1-13) was the initial learning period; phase 2 (cases 14-44) was the learning plateau period; and phase 3 (cases 45-85) was the competent period. The differences in total operating time among the three phases were significant. The number of harvested lymph nodes increased along with increases in the surgeon's experience.

CONCLUSIONS

For experienced CLS surgeons, the learning process reached the plateau period after the 13th case, and technical competence was achieved after the 44th case.

Safety and feasibility of single-port laparoscopic low anterior resection for upper rectal cancer

BACKGROUND

Single-port surgery for rectal cancer is challenging and controversial. The aim of this study was to compare the short-term outcomes of single-port laparoscopic low anterior resection (S-LAR) to multi-port laparoscopic low anterior resection (M-LAR) for upper rectal cancer.

METHODS

From January 2011 to December 2015, a total of 93 patients who underwent S-LAR (n = 44) or M-LAR (n = 49) without protective diverting ileostomy for upper rectal cancer were identified. Tumors were located between the inferior margin of the second sacral vertebra and the peritoneal reflection. Short-term outcomes were compared between groups.

RESULTS

S-LAR was successful in 75% of cases: 25% of cases required one additional port. Operative factors, perioperative outcomes, oncological outcomes did not differ significantly between groups. In patients with stage I-III disease, the 3-year relapse-free survival rate was significantly higher in the S-LAR group than in the M-LAR group (p = 0.032). The 3-year overall survival rate was similar between groups.

CONCLUSIONS

S-LAR is safe, feasible and can provide satisfactory oncological outcomes in selected patients with upper rectal cancer.

Single Port and Conventional Laparoscopy in Colorectal Surgery: Comparison of Two Techniques

BACKGROUND

Single-incision laparoscopic surgery (SILS) was introduced to further the enhanced outcome of conventional multiport laparoscopy (CML). We compared their short- and long-term outcomes in colorectal surgery.

MATERIALS AND METHODS

Retrospective review of patients who underwent elective laparoscopic colorectal surgery during 3-year period. Patients' data, surgery outcomes, and oncological results were compared.

RESULTS

Sixty-one patients (33 male, 28 female), mean age 67.4 years, underwent laparoscopic colonic resections: 28 SILS and 33 CML. Twenty-three (37.7%) patients had previous abdominal surgery. There were 19 (31.2%) right, 9 (14.7%) left, and 2 (3.3%) total colectomies, 16 (26.2%) sigmoidectomies, 13 (21.3%) anterior and 2 (3.3%) abdominoperineal resections. Colonic malignancy was a main indication for the surgery in 51 (83.6%) patients. Mean surgery time and postoperative stay were 92.0 minutes and 9 days, respectively. Pathological examination revealed stage I colon cancer in 16 (32%), stage II in 22 (44%), stage III in 10 (20%), and stage IV in 2 (4%) patients. Mean number of retrieved lymph nodes was 19 ± 13.5. No differences were found between groups in demographic data, type of surgery, surgery time and hospital stay, pathological results and tumor staging, and disease-free and overall survivals. In the SILS group, placement of additional trocar was required in 7 (25%) and conversion in 3 (10.7%) cases compared with 1 (3%) case of conversion to formal laparotomy in the CML group. Overall postoperative morbidity was 16.4%. There was no mortality in both the groups. During the study period, 3 patients from the CML group had cancer recurrence.

CONCLUSIONS

SILS is a feasible and safe technique compared with CML in terms of surgical and oncological outcomes.

Oncologic outcomes of single-incision laparoscopic surgery for right colon cancer: A propensity score-matching analysis

BACKGROUND

The aim of this study was to investigate oncologic, perioperative, and pathologic outcomes of single-incision laparoscopic right hemicolectomy (SILRC) compared to conventional laparoscopic right hemicolectomy (CLRC) for right colon cancer using propensity score-matching analysis.

MATERIALS AND METHODS

From November 2009 through September 2014, 260 consecutive patients underwent laparoscopic surgery for right colon cancer. Data on short-term and long-term outcomes were collected and reviewed. Propensity score-matching was applied at a ratio of 1:2 to compare the SILRC (n = 40) and the CLRC (n = 80) groups.

RESULTS

Operation time, estimated blood loss, time to diet were not different; however, the SILRC group showed less pain on operative day and postoperative day #2 (4.8 vs. 5.9, p < 0.001 and 3.6 vs. 4.6, p = 0.006, respectively) as well as shorter incision lengths (4.0 vs. 7.3 cm, p < 0.001). Morbidity, mortality, and pathologic outcomes were similar between groups. The 3-year overall survival rates were 96.0% vs. 97.5% (p = 0.740), and disease-free survival rates were 93.5% vs. 97.5% (p = 0.444) in the SILRC and the CLRC groups, respectively.

CONCLUSION

The long-term oncologic outcomes as well as short-term outcomes of SILRC were comparable to CLRC. It appears to be a safe and feasible option with shorter incision lengths.

Long-term Outcomes of Single-Site Laparoscopic Colectomy With Complete Mesocolic Excision for Colon Cancer: Comparison With Conventional Multiport Laparoscopic Colectomy Using Propensity Score Matching

BACKGROUND

Complete mesocolic excision has been suggested to improve oncological outcomes for patients with colon cancer. However, the long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision remain unclear.

OBJECTIVE

We evaluated the long-term outcomes of single-site laparoscopic colectomy with complete mesocolic excision compared with conventional multiport laparoscopic colectomy for colon cancer, as well as the short-term outcomes.

DESIGN

This is a single-center, retrospective study.

SETTINGS

The study was conducted at Osaka University Hospital in Japan.

PATIENTS

A total of 971 consecutive patients who underwent laparoscopic surgery for colon cancer between 2008 and 2014 were included. Of these patients, 517 were analyzed using propensity score matching (231 with single-site laparoscopic colectomy and 286 with conventional multiport laparoscopic colectomy).

MAIN OUTCOME MEASURES

Recurrence, survival, intraoperative morbidity, and postoperative complications were analyzed.

RESULTS

Before propensity score matching, the single-site laparoscopic colectomy group had greater proportions of women and of patients with right-sided and early stage tumors compared with the conventional multiport laparoscopic colectomy group. After matching, the 2 groups each included 200 patients and did not significantly differ in any patient characteristics. The median follow-up period was 41.4 months. The 2 groups showed similar rates of intraoperative morbidity (p = 0.22) and postoperative complications (p = 0.87). Rates of 3-year disease-free and overall survival in single-site laparoscopic colectomy and conventional, multiport, laparoscopic colectomy groups were 95.5% and 91.3% (p = 0.44) and 100.0% and 98.7% (p = 0.24). The 3-year disease-free and overall survival rates in each stage did not significantly differ between the 2 groups.

LIMITATIONS

This study was limited by its retrospective nature.

CONCLUSIONS

Single-site laparoscopic colectomy with complete mesocolic excision for colon cancer provided acceptable perioperative outcomes and oncological outcomes, similar to those achieved with conventional multiport laparoscopic colectomy. Evidence accumulation from randomized controlled trials will be necessary to promote the wide acceptance of single-site laparoscopic colectomy. See Video Abstract at http://links.lww.com/DCR/A326.

Impact of obesity on the short-term outcomes of single-port laparoscopic colectomy for colorectal cancer in the Asian population: A retrospective cohort study

Single-port laparoscopic surgery (SPLS) is being increasingly performed for treating colorectal cancer. Here, we aimed to assess the safety and feasibility of SPLS for colorectal cancer in obese patients through a comparison of their short-term outcomes with those of nonobese patients.A total of 323 patients who underwent SPLS for colorectal cancer at our center between March 2009 and August 2014 were enrolled. The outcomes were analyzed according to the body mass index (BMI) category: nonobese (BMI < 25), obese I (BMI: 25.0-29.9), and obese II (BMI ≥ 30).Of the 323 patients, 233 (72.1%), 80 (24.8%), and 10 (3.1%), were assigned to the nonobese, obese I, and obese II groups, respectively. The clinicopathologic patient characteristics, such as age, gender, tumor location, and previous laparotomy, were similar among the 3 groups. The mean operative time (nonobese vs obese I vs and obese II groups: 269.2 vs 270.4 vs 342.8 minutes, respectively) and estimated surgical blood loss (277.7 vs 260.5 vs 387.0 mL, respectively) were greater in the obese II group than in the nonobese and obese I groups, although the difference was not significant (P = .247 and P = .205, respectively). However, the time to passage of flatus significantly differed among the groups (P = .040); in particular, this value was significantly longer in the obese II group than in the obese I group (P = .031). None of the other parameters, including conversion to open or conventional laparoscopic surgery and intra- and postoperative morbidity, significantly differed among the 3 groups.SPLS for colorectal cancer can be safely performed in obese Asian patients with equivalent short-term outcomes as compared with that in nonobese patients. Hence, SPLS can be safely recommended for colorectal cancer in obese patients if the surgeon is experienced. Nevertheless, the technique used warrants further investigation, and a large-scale prospective study is required.

Assessment of treatment options for rectosigmoid cancer: single-incision plus one port laparoscopic surgery, single-incision laparoscopic surgery, and conventional laparoscopic surgery

BACKGROUND

The advantages of reduced-port laparoscopic surgery (RPLS) for rectosigmoid cancer treatment have been disputed. This study evaluated the outcomes of RPLS compared to conventional laparoscopic surgery (CLS) for rectosigmoid cancer.

METHODS

Data from 211 patients who underwent a selective sigmoidectomy or anterior resection from August 2011 to June 2014 at a single institution were collected and analyzed via propensity score matching. Operative outcomes, inflammatory responses, pain intensity, oncologic outcomes, quality of life, and cosmetic results were compared between groups.

RESULTS

After matching, 96 patients (48 CLS and 48 RPLS) were evaluated. Sixteen RPLS cases underwent single-incision laparoscopic surgery (SILS), and 32 underwent single-incision plus one port laparoscopic surgery (SILS + 1). Baseline clinical characteristics were comparable between the RPLS and the CLS groups. Morbidity, pathologic outcomes, and 3-year disease-free survival and overall survival rates were also comparable between the 2 groups. Compared with the CLS group, the RPLS group had a shorter total incision length (p < 0.001); shorter time to liquid diet (p = 0.027), ambulation (p = 0.026), and discharge (p < 0.001); and lower visual analogue scale scores during mobilization at postoperative days 3-5 (p < 0.05). The total operation times, C-reactive protein levels at 24 h and 96 h, and interleukin-6 levels at 24 h postoperatively were significantly lower in the SILS + 1 group than those in the CLS and SILS groups (p < 0.05). Compared with the CLS group, the RPLS group showed better social functioning at 6 months postoperatively (p = 0.011). The SILS and SILS + 1 groups showed similar cosmetic results, and both groups showed better results than the CLS group (p < 0.001).

CONCLUSIONS

RPLS for rectosigmoid cancer is feasible, with short-term safety and long-term oncological safety comparable to that of CLS. Better cosmesis and accelerated recovery can be expected. SILS + 1 is a better choice than CLS or SILS for rectosigmoid cancer because it minimizes invasiveness and reduces technical difficulties.

Single-Incision Laparoscopic Anterior Resection Using a Curved Stapler

INTRODUCTION

Single-incision laparoscopic colectomy is technically limited because of such factors as instrument crowding, in-line viewing, and insufficient countertraction. In particular, it is technically difficult to cut the distal rectum from the umbilicus using an articulating linear stapler in single-incision laparoscopic anterior resection.

TECHNIQUE

After treating the mesorectum, the 5-mm trocar is replaced with a 12-mm trocar. The cartridge of the curved stapler is mounted while the shaft of the stapler is inserted into the 12-mm port extracorporeally. The curved stapler is inserted through the umbilical incision with the cartridge. A multichannel port is then mounted, and the abdominal cavity is reinsufflated. The curved stapler can then be operated intracorporeally. This procedure facilitates the vertical dissection of the rectum from the umbilicus.

RESULTS

A total of 27 consecutive patients were analyzed in this study. All the procedures were safely performed without any complications. The median distance from the peritoneal reflection to the transection point of the distal bowel in single-incision laparoscopic anterior resection was 5.0 cm (range, -2.0 to 15.0). One stapler firing was required to achieve distal bowel division in 26 patients (96.3 %), whereas 2 firings were required in 1 patient (3.7 %). The median distal margin was 7.0 cm (range, 3.0-13.0). The time from the insertion of the stapler to transection was 180 seconds (range, 100-420). There were no cases of anastomotic leakage.

CONCLUSIONS

In single-incision laparoscopic anterior resection, it is feasible to perform rectal transection from the umbilicus by using a curved stapler. This technique may allow for the omission of 1 trocar from the operation.

Reduced port laparoscopic surgery for colon cancer is safe and feasible in terms of short-term outcomes: comparative study with conventional multiport laparoscopic surgery

Purpose

Laparoscopic surgery was previously accepted as an alternative surgical option in treatment for colorectal cancer. Nowadays, single-port laparoscopic surgery (SPLS) is introduced as a method to maximize advantages of minimally invasive surgery. However, SPLS has several limitations compared to conventional multiport laparoscopic surgery (CMLS). To overcome those limitations of SPLS, reduced port laparoscopic surgery (RPLS) was introduced. This study aimed at evaluating the short-term outcomes of RPLS.

Methods

Patients who underwent CMLS and RPLS of colon cancer between August 2011 and December 2013 were included in this study. Short-term clinical and pathological outcome were compared between the 2 groups.

Results

Thirty-two patients underwent RPLS and 217 patients underwent CMLS. Shorter operation time, less blood loss, and faster bowel movement were shown in RPLS group in this study. In terms of postoperative pain, numeric rating scale (NRS) of RPLS was lower than that of CMLS. Significant differences were shown in terms of tumor size, harvested lymph node, perineural invasion, and pathological stage. No significant differences were confirmed in terms of other surgical outcomes.

Conclusion

In this study, RPLS was technically feasible and safe. Especially in terms of postoperative pain, RPLS was comparable to CMLS. RPLS may be a feasible alternative option in selected patients with colon cancer.

Randomized clinical trial of single-incision versus multiport laparoscopic colectomy

BACKGROUND

The efficacy and safety of single-incision laparoscopic colectomy (SILC) for colonic cancer remain unclear. The aim of this study was to determine the outcomes of SILC compared with multiport laparoscopic colectomy (MPLC) for colonic cancer.

METHODS

Patients with histologically proven colonic carcinoma located in the caecum, ascending, sigmoid or rectosigmoid colon, clinically diagnosed as stage 0-III by CT, were eligible for this study. Patients were randomized before surgery and underwent tumour dissection with complete mesocolic excision. Safety analyses were conducted according to randomization groups.

RESULTS

A total of 200 patients were enrolled and randomized to the MPLC (100 patients) or SILC (100 patients) arm. Surgical outcomes were similar between the MPLC and SILC arms, including duration of operation (mean 162 versus 156 min respectively; P = 0·273), blood loss (mean 8·8 versus 21·4 ml; P = 0·102), conversion to open laparotomy (2·0 versus 1·0 per cent; P = 0·561), reoperation (3·0 versus 3·0 per cent; P = 1·000), time to first flatus (both median 1 day; P = 0·155) and postoperative hospital stay (both median 6; P = 0·372). The total skin incision length was significantly shorter in the SILC arm (mean 4·4 cm versus 6·8 cm in the MPLC arm; P < 0·001). The median duration of analgesia use was 5 days in the MPLC and 4 days in the SILC arm (P = 0·485). Overall complication rates were equivalent (15·0 versus 12·0 per cent respecitvely; P = 0·680).

CONCLUSION

SILC is not superior to MPLC.

REGISTRATION NUMBER

UMIN000007220 (http://www.umin.ac.jp/ctr/index.htm).

Single incision gastrectomy for gastric cancer

Based on rapid development of laparoscopic techniques and instruments, single-incision laparoscopic surgery (SILS) is expected to be the next step of "more" minimally invasive surgery. A few institutions gradually started to report their experience of single incision gastrectomy (SIG) for gastric cancer, but it is still difficult to accept that SIG can be performed as a popular procedure because of its technical difficulty. For wide adoption of SIG, the simplicity, safety and reproducibility of not only lymph node dissection but also reconstruction should be evaluated compared to a conventional procedure. With a thorough understanding of unique characteristics of SILS, single incision distal gastrectomy (SIDG) for early gastric cancer performed by laparoscopic surgeons with advanced technique is expected to have promising potential about excellent cosmesis, comparable morbidity and mortality in carefully selected patients. For appropriate adoption and steady progress of this state-of-the art surgery, scientific evaluation with healthy critics is necessary with new generation of SILS instrument platform.